Do we need training to say ‘no’ more often?

People management skills are key in medical practice and yet we are expected to pick them up rather than receive structured training – and it’s impacting our ability to deal with increasingly difficult behaviours and expectations.

Stroppy or stressed out patients making rude and unreasonable demands has sadly become a common sight in general practice. A recent Healthed survey showed that 72% of GPs have observed a change in patient attitudes and expectations over the past three years.

Here are some of the worst situations GPs have told us about:

A female patient told me to go f**k myself in response to suggesting probiotics for her child’s gastro.

When a drug addict who was yelling at my staff was asked to calm down and leave, he said, ‘I’ll fix you, you little shit.’ Then, he attacked me. (I am trained in martial arts and I’m a body builder. He never managed to land a punch.)

An angry patient tried to hit me with his fist. I talked him out of it.

I was verbally abused about running late. I advised the patient to attend another practice because l could no longer provide him with care.

I was screamed at for not issuing mask exception I left the room and told the patient to leave.

A patient thumped the desk and was demanding. I told the patient not to threaten me. The patient continued to thump the desk. I told the patient to leave or I would call the police. After saying this three times, she finally left.

Once, people were held hostage in our practice. The police were outside the door. I will never forget it. It lasted for hours.

A gun was put to my head by a patient’s heavily intoxicated companion while doing a house call. I kept my composure and I used my professional skills of de-escalating the situation.

Most experienced GPs will have seen this kind of extreme behaviour on their worst days in the clinic, but even on an average day, strong interpersonal and conflict management skills get a good workout.

What can GP practices do in response to deteriorating patient behaviour?

In the 11 October Healthed survey, around 300 GPs indicated that they would like training in conflict management (56%), time management (50%), assertiveness (42%) and negotiation skills (42%) to help manage patient behaviour.

Some GPs indicated that they wanted customer service training, cultural awareness training and even self defence training.

“We get taught about ethics and medico-legal obligations at medical school, but we’re never actually taught about how to establish boundaries with patients,” says Dr Aajuli Shukla, a GP based in Western Sydney and an editor at Healthed.

“We’re not actually given any assertiveness training. So, we start our medical careers with a gap.”

General practitioners tend to see patients at their “absolute most vulnerable”, and it falls on GPs to do much of the work that social workers would be doing in a hospital setting, says Shukla. “It can be very tricky to establish boundaries and be assertive with patients who are in distress.”

Most GPs see boundary-setting as a relative weakness

“GPs occupy a unique position in that they are much more involved in people’s lives than other service providers,” says a GP on Healthed’s Advisory Board.

“You might expect simple black-and-white boundaries but they aren’t real when you become deeply embedded in your patient’s life and community. That is simultaneously one of the rewarding things about GP but also the most difficult to navigate.”

In Healthed’s recent survey, around 80% of GPs rated their boundary-setting skills as average or below average. This is not surprising; “This is like saying the sky is blue,” says a GP on Healthed’s Advisory Board.

“The upside of general practice is you share the joys and sorrows of your patients but the downside is that it’s hard to set those boundaries,” he says.

A further analysis of this data suggested that older GPs felt they were better at boundary-setting than younger GPs, although the sample size was small.

A similar distribution appeared when Healthed asked GPs ‘How would you rate your ability to manage time?’

Dr Pradeep Jayasuriya, a GP based in Western Australia, says GPs are more at risk of boundary incursion than any other specialist.

This is because GP relationships with patients are deep and long-term, and the quality of care is correlated with the quality of the relationship.

“GPs have to fly very close to those boundary regions,” he says. “The more familiar you are with a patient, the more likely you are to make concessions around the boundaries you may have set. Sometimes that happens consciously and sometimes it’s unconscious.”

The patient might ask the GP to fill out a form or write a letter. They might request that the GP write an extra script for a family member they’ve brought along to the appointment. For each individual case, it’s just a small ask that may seem unreasonable to refuse, but at a system level, repeatedly giving in causes delays.

“It’s usually easier to fulfill the request than to say ‘no’ and deal with potential conflict,” says Jayasuriya. “GPs take the path of least resistance and start running behind. But, in doing so, they set a precedent and end up doing it again.”

System-based approaches are needed to address this issue, says Jayasuriya. (Read more on this point in Part 2 of this story.)

‘GPs are tolerance machines’

Dr Todd Cameron, a GP practice owner and business coach who has worked with over 100 practices around the country, says “GPs are tolerance machines” who are conditioned to continue absorbing stress rather than pushing back.

“A fair bit can be thrown at you in a day’s work,” he says. “The things that are going on in patients’ lives may be deeply personal to you. It’s distressing when somebody that you know and like is experiencing psychological or family distress.”

The tendency for GPs to genuinely care about their patients, and their acclimatisation to chronic stress, means they often respond to system pressures by working harder and taking on more responsibility, which is often anathema to boundary setting.

This effect is heightened during a pandemic where healthcare services such as vaccines need to be urgently delivered at scale, unexpected admin work increases, hospitals and mental health services are swamped and specialist appointments are delayed, says Cameron.

“General practice is the first and third port of call,” he says. When patients have “nowhere to go” because they can’t get in to see a psychiatrist or are on a six-month waiting list for surgery, it’s the GP who consoles the patient and addresses their immediate healthcare needs, he says.

Hurt people hurt people

Another important factor that may influence the ability to manage patients and set boundaries is the psychological state of the patients themselves.

“People are more irritable now,” says Cameron. The stress of the pandemic, the rising cost of living and global tensions all “play into people’s background levels of comfort or anxiety”, he says. “And often those are brought into the consult.”

Changing norms around billing in general practice can also catch patients off guard. Patients can become frustrated when they are used to getting a service for free and now have to pay, says Cameron. “It brings a further level of angst,” he says.

However, it’s often only a small subset of patients who are difficult to manage. In the Healthed survey, 62% of GPs said they had trouble setting boundaries with around a quarter of their patients.

Around one-fifth of GPs (21%) said none of their patients were difficult to set boundaries for, and 11% of GPs said around half of their patients were challenging in this respect.

And there are generally specific reasons why some patients find it difficult to accept boundaries set by the GP. In Healthed’s survey, 61% of GPs said that patients who are emotionally distressed had difficulty respecting boundaries.